Signs and Symptoms
- General:
- Weakness and fatigue
- Tachycardia
- Tachypnea
- Hypotension
- Cool, clammy skin; prolonged capillary refill
- Abdominal:
- Significant active upper GI bleeding:
- Hematemesis
- Hematochezia
- Melena
- 20-40% of total blood volume loss possible
- Abdominal pain
- Stigmata of severe hepatic dysfunction:
- Jaundice
- Spider angiomata
- Palmar erythema
- Pedal edema
- Hepatosplenomegaly
- Ascites
- History of portal hypertension:
- Most commonly alcoholic cirrhosis
- Others, including:
- Primary biliary cirrhosis
- Schistosomiasis
- Budd-Chiari syndrome
- Severe CHF
- Sarcoidosis
- Cardiovascular:
- Chest pain/shortness of breath
- CNS:
- Syncope
- Confusion and agitation initially
- Lethargy and obtundation later
Pediatric Considerations |
- Massive hematemesis is typical initial presentation
- Hypotension may be a late finding
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History
- Gastroesophageal varices are present in 50% of patients with cirrhosis and correlate with severity of disease
- The most important predictor of hemorrhage is size of the varices. Other factors include number of varices, severity of hepatic disease, and endoscopic findings
- Patients with PBC develop varices and variceal hemorrhage early in their course of disease, even prior to development of cirrhosis
Physical Exam
- Vitals signs may be normal or may show tachycardia (early) and hypotension (late)
- Altered mental status with encephalopathy or poor perfusion
- Active hematemesis
- Stigmata of alcoholic liver disease:
- Ascites
- General edema
- Jaundice
Essential Workup
- Gastric tube placement:
- Determines whether patient is actively bleeding
- Decompresses stomach that may aid in hemostasis. Possible role in reducing aspiration risk
- Facilitates endoscopic exam
- Will not increase or cause esophageal variceal bleeding
- Emergent endoscopy
Diagnostic Tests & Interpretation
Lab
- Type and cross-match 6-8 U:
- Significant transfusion requirements
- ABG for:
- CBC:
- Hematocrit is an unreliable indicator of early rapid blood loss
- Perform serial CBCs to follow blood loss
- Electrolytes, BUN, creatinine, glucose:
- Evaluate renal function
- BUN: Creatinine ratio >30 suggest significant blood in GI tract and upper GI source
- PT/PTT/INR and platelets:
- Coagulopathy
- Prolonged bleeding times
- Thrombocytopenia
Imaging
- CXR (portable) for aspiration/perforation
- ECG for myocardial ischemia
Differential Diagnosis
- Bleeding/perforated peptic ulcer
- Erosive gastritis
- Mallory-Weiss syndrome
- Boerhaave syndrome
- Aortoenteric fistula
- Gastric varices
- Gastric vascular ectasia
Prehospital
- Airway stabilization
- Treat hypotension with 0.9% normal saline infusion bolus through 2 large-bore IV lines
- Cardiac and pulse oximetry monitoring
Initial Stabilization/Therapy
- ABCs with early aggressive airway control/intubation:
- Early intubation = easier intubation
- For AMS or massive hemoptysis
- Facilitates emergency endoscopy
- Establish central IV access with invasive intravascular monitoring for hypotension not responsive to initial fluid bolus
- Replace lost blood as soon as possible:
- Initiate with O-negative blood until type-specific blood available
- 10 mL/kg bolus in children
- Fresh-frozen plasma and platelets may be required
- Correct coagulopathies as needed
- Place gastric tube nasally (awake) or orally (intubated)
- Restrictive transfusion strategy:
- Overly aggressive volume expansion may lead to rebound portal HTN, rebleeding, and pulmonary edema
- Transfusion goal is Hb = 7 for most
- Transfusion goal of Hb 9 in older patients or if significant comorbidities
Pediatric Considerations |
- Initiate intraosseous access if peripheral access unsuccessful in unstable patient
- Most bleeding in children stops spontaneously
- Vital sign changes may be a late finding in children:
- Subtle changes in mental status, capillary refill, mild tachycardia, or orthostatic changes may indicate significant blood loss
- Overaggressive correction in infants can quickly lead to significant electrolyte abnormalities
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ED Treatment/Procedures
- Emergent endoscopy required for active bleeding:
- Use pharmacologic and tamponade devices as temporizing measures
- Endoscopy:
- Emergent with active bleeding in nasogastric tube, goal within 12 hr of presentation
- Procedure of choice in acute esophageal bleeding
- Esophageal band ligation equivalent to sclerotherapy with fewer complications:
- May be difficult to visualize in cases of massive bleeding
- Sclerotherapy with massive bleeding
- Gastric varices are not amenable to endoscopic repair due to high rebleeding rate:
- Administer antibiotics at time of procedure to decrease risk for spontaneous bacterial peritonitis:
- Pharmacologic therapy:
- Terlipressin is first-line therapy where available (not widely available in the U.S.) due to greater efficacy and fewer side effects
- Octreotide is first-line therapy where terlipressin not available:
- Complications include hyperglycemia and abdominal cramping
- Vasopressin has been replaced by octreotide secondary to high incidence of vascular ischemia
- PPIs are not indicated in the treatment of variceal bleeding
- Balloon tamponade:
- Initiate in massive uncontrollable bleed
- Sengstaken-Blakemore and Minnesota tubes
- Applies direct pressure but risks esophageal perforation and ulceration, asphyxiation from tracheal compression, and aspiration
- Temporary benefit only, used as means of stabilization until endoscopy available
- Refractory bleeding therapy:
- Interventional radiology:
- Transjugular intrahepatic portosystemic shunt procedure is recommended for refractory gastric varices or for patients who are poor surgical cand idates
- Surgical options:
- Portacaval shunt
- Esophageal transection
- Gastroesophageal junction devascularization
Medication
- Ceftriaxone: 2 g (peds: 50-75 mg/kg/24 hr) IV q24h in Child-Pugh class B/C or in quinolone-resistant areas
- Cefotaxime: 2 g (peds: 50-180 mg/kg/24 hr) IV q8h
- Erythromycin: 250 mg IV
- Shown to aid in gastric clearing for better visualization during endoscopy
- Norfloxacin: 400 mg PO q12 or ciprofloxacin 400 mg IV q12 if cannot tolerate PO (contraindicated in peds)
- Octreotide: 50 mcg bolus, then 50 mcg/hr infusion for 5 d. Pediatric dosing: 1-2 mcg/kg bolus (up to 50 mcg), then 1-2 mcg/kg/hr infusion. Elderly: 25 mcg bolus, then 25 mcg/hr infusion for 5 d
- Terlipressin: 2 mg IV q4h
- Somatostatin: (If octreotide not available) 250 mcg IV bolus followed by 250 mcg/hr IV infusion for 5 d
- Vasopressin: (If octreotide not available). Pediatric dosing: 0.002-0.005 U/kg/min (titrated to max of 0.01 U/kg/min)
First Line
- Terlipressin or octreotide (if terlipressin not available)
- Norfloxacin PO or ciprofloxacin IV
Disposition
Admission Criteria
- ICU admission for actively bleeding varices, hemodynamic instability, airway management
- Recent history of variceal bleeding
- High risk for early rebleeding:
- Age >60 yr, renal failure, initial hemoglobin count <8
Discharge Criteria
Nonbleeding varices
Issues for Referral
- Continued hemorrhage requiring surgery or higher level of care
- Liver transplant
Follow-up Recommendations
- Timely outpatient GI follow-up:
- Will need annual surveillance endoscopies
- Medication and lifestyle modifications
- Chavez-TapiaNC, Barrientos-GutierrezT, Tellez-AvileFl, et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding . Cochrane Database Syst Rev. 2010;(9):CD002907.
- HwangJH, ShergillAK, AcostaRD, et al. The role of endoscopy in the management of variceal hemorrhage . Gastrointest Endosc. 2014;80:221-227.
- VillanuevaC, ColomoA, BoschA, et al. Transfusion strategies for acute upper gastrointestinal bleeding . N Engl J Med. 2013;368(1):11-21.
- World Gastroenterology Organisation (WGO). Esophageal varices. World Gastroenterology Organisation Global Guidelines (online text) . 2014. Available at http://www.worldgastroenterology.org/UserFiles/file/guidelines/esophageal-varices-english-2014.pdf. Accessed March 16, 2018.
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